Summary/Key Points

From this surgeon’s perspective, based on over 14 years of experience with effectively only saline-filled implants available for primary augmentation in the US, saline-filled implants have to be sized properly, positioned properly, and filled properly to get a result that looks like a silicone gel implant; but they still do not feel like one. Silicone gel-filled implants do not require the same attention to detail to get an optimal looking and feeling result.

Patient Selection

The patient considering breast augmentation should be thoroughly evaluated, examined, and prepared by the operating surgeon. There is no true substitute for this and the use of patient coordinators, nurses, office personnel, and printed information, videos, websites, and picture examples are merely adjuncts to the process of proper patient selection and preparation.

Given that nothing needs or should be done to the breast parenchyma and there is no change in the risk of breast cancer from the procedure¹ a routine mammogram should not be required of patients preoperatively if there is otherwise no reason for one. If the patient needs a mammogram based on their age, physical findings, or some other reason, then they should have one done before the procedure.¹

Physical findings of the breast that would preclude the patient from primary cosmetic breast augmentation as a sole procedure include active breast disease or undiagnosed palpable abnormality of the breast. Previous treatment for breast cancer or radiation treatment would put the patient in the category of breast reconstruction. Ptosis of the breast beyond about 2 cm into Grade II² is a cosmetic contraindication to primary breast augmentation in my experience. Two centimeters or less can be compensated for using a properly placed breast implant and is usually of more benefit than any type of mastopexy procedure as long as the patient is willing to accept the increase in volume and understands that an implant will not truly lift the breast but only fills it out.

One of the listed complications of cosmetic surgery that is perhaps too common but can be avoided is the aesthetic risk of dissatisfaction with the result. This is best avoided by telling the patient what a breast augmentation can do and can’t do and what the patient can choose for her own reasons and what is being done based on experience of the surgeon on how to get the best result (Table 22.1).

Table 22.1 Key to getting a good result

The key to consistent natural results with saline-filled implants requires thinking dimensionally as in fitting a woman for clothes or fitting an orthopedic implant and giving up thinking in terms of volume alone. This can all be done preoperatively and should not require choices made during surgery.

Avoiding visible rippling requires:

• Partial subpectoral positioning • A smooth surface, round implant • Matching the width of the implant to the width of the breast (excluding the skin and some of the subcutaneous tissue); • Centering the round implant properly in relation to the nipple–areola and inframammary crease; • Filling the implant to its rated volume and no more than 10% additional volume.

If the saline-filled breast implant is sized correctly, positioned correctly, filled correctly, and healed in the proper position, the result should look just like a result with a gel-filled implant in the majority of patients. Gel-filled implants are much more forgiving regarding sizing and positioning and there are no filling issues. Palpable feel of the saline-filled implant, ‘rippling’ that is felt and not seen in the upright position, cannot be avoided with a saline-filled device but can be graded and understood by the patient at least for the immediate postoperative period.

The other area that is often missed in the evaluation of patient selection is whether the patient has adequately prepared for the recovery. Contrary to efforts by some to convince the patient that they can return to normal activity the next day,³ I recommend treating breast augmentation as an orthopedic procedure and require that the patient has a week off from any and all required activities other than taking care of herself. This helps to magnify the consequences of the procedure and the importance of the recovery in the overall result as well as help to avoid precipitous surgery and poorly thought out choices. It also allows for the enormous variation in perceived pain and recovery difficulty among patients after what is ostensibly the same procedure.

Indications

As with all purely cosmetic procedures, there is a sense in which there are no indications for the procedure; there are only contraindications and most of those are relative. No patient really needs a breast augmentation and few are contraindicated for physical or health reasons. There are, of course, a number of relative contraindications but these can be properly determined by appropriate consultation and exam.

Here we will be mainly dealing with the choice of saline-filled breast implants over silicone gel-filled implants. The simple answer to this is that today most properly informed patients can choose whether they want saline or gel implants and the surgeon should honor that choice and not try to make it for the patient. This presumes only that the surgeon has experience with both types of implants and can offer either of them from adequate experience. The patient acknowledges the appropriate informed consent for the type of breast implant used.

A simple way to describe the asymmetric choice of saline or gel implants is to say that saline implants have a lot of advantages and one big disadvantage and silicone gel implants have a lot of disadvantages and one big advantage. How the individual woman weighs these advantages and disadvantages for her personal reasons and breast characteristics should allow her to choose one over the other.

There are several issues such as capsule contracture rates and implant failure rates that I do not consider resolved adequately and will not address, but of the established factors for saline-filled breast implants, their advantages are:

Their major disadvantage is their inherent watery or ripply feel.

Silicone gel-filled breast implants have several disadvantages:

Their major advantage is their inherent natural or tissue-like feel.

Thus, the indications for the use of saline-filled breast implants in primary breast augmentation are that the patient feels their advantages over gel-filled implants outweigh their disadvantages and the surgeon knows how to prepare the patient for the disadvantage of saline implants and how to get an optimal result with one.

Preoperative Planning

As part of the evaluation, preparation, and informed consent for a woman considering primary breast augmentation and the choice of saline-filled or gel-filled implants; she should be shown where the implant is going to be easiest to feel and to what degree she will be able to feel it with her current skin tone, subcutaneous fat, and breast tissue. It should be clearly stated that this is feel to the patient and not looks or feel to someone else unless it is pointed out to them or they know the implant is there and where to feel.

Degree of coverage starts from a rating of near zero and completely inadequate in a woman with thin or very soft skin, virtually no subcutaneous fat, and essentially no breast tissue. This is a situation comparable to someone whose ribs are sticking out or a woman who has had an aggressive subcutaneous mastectomy or full mastectomy. Perfect coverage would be rated a 3 with thick elastic skin, normal or more subcutaneous fat, and average breast tissue. In that situation, the woman is not going to be able to feel the implant to any significant degree and it won’t matter whether it’s saline-filled or gel-filled. In between the extremes are where most patients fall and there are those who have adequate coverage laterally but inadequate in the inferior pole, particularly in the somewhat ptotic or pseudo-ptotic (Fig. 22.1).

The patient has chosen saline implants and the profile of the implant. The width of the implant is determined by the width of the breast (Figs 22.2 and 22.3). Therefore, the correct implant is known before the procedure and can be confidently placed without using sizers, sitting the patient up during the procedure, or making choices for the patient on the operating table (Fig. 22.4A–C).

This type of dimensional planning is crucial for getting the best results with saline implants and is also, apparently, important for technique in fourth generation, cohesive gel implants. Second and third generation gel-filled implants allowed for volumetric thinking in cosmetic breast augmentation, but saline implants are far less forgiving.

The only other marking required preoperatively is the position of the inframammary crease in the upright position. On the operating table, the distance from the medial border of the breast to the nipple (or medial edge of the areola) can be measured under no tension and compared to the distance from the nipple (or inferior edge of the areola) under tension. With few exceptions related to extreme lateral positioning of the nipple–areola, comparing these two measurements determines whether a round implant of the width of the inner diameter of the breast will fit and seat properly behind the nipple–areola. If the distance to the inframammary crease is too short, the crease must be lowered to the appropriate level and re-established and healed in the new position (Fig. 22.2A, B).

During the preoperative consultation, the physical characteristics of the breast should be noted and pointed out to the patient (see Box 22.1).

With the characteristics listed in Box 22.1, it can be determined whether a round implant will fill out the breast adequately, the width of the implant that will fit it, whether the inframammary crease will need to be adjusted, how much soft tissue coverage is available to make the saline-filled implant less palpable, and any issues the patient needs to be aware of that will not be corrected by a breast implant alone.

Tissue coverage for the implant is based on the skin, subcutaneous fat, and breast tissue on the lateral side and underside of the breast. This gives a three-point scale ranging from no problem for saline implant coverage (III) to big problem for coverage of saline implants (I). This could change in the future as the breast changes, but it must be based on the conditions present at the time of the operation and the patient informed of it.

The width of the breast across the center (usually across the nipple–areola) measured with a caliper in the upright position with arms down, determines the width of the implant; 0.5–1 cm is subtracted from this measured number depending on the thickness of the patient’s skin and overlying tissues at the edge of the breast. The diameter of the implant can then be looked up in the chart of available implants. In saline implants from Allergan or Mentor the patient chooses the forward profile volume scaled to the width: low (Allergan), medium (Mentor, Allergan), medium plus (Mentor), or high (Allergan), and the volume of the implant as well as the size characteristics (within the fill range) are determined. If the patient’s breast width is average (not too wide or narrow) for her chest circumference, the profile choice corresponds to an increase of one apparent bra cup size (low profile), a cup and a half increase (medium profile), a two cup size increase (high profile), and between a cup-and-a-half and two cups (medium plus). This is relative to where the patient started and is admittedly inexact.

It is important to point out that there is no current simple way to measure breast size preoperatively or postoperatively. There is also no realistic way to show it or measure it using external means. The best that can be done, in my experience, is to tell the patient what cup size she looks like compared to other women with her chest diameter and therefore what size she could achieve depending on her choice of profile. This does not mean what size brassiere she wears now or what ‘fits’ her and does not mean what size brassiere she will wear later on or what size ‘fits’ her. The only other method I find useful is to show prior patients’ results in standardized views with different profile implants.

Notice that there is no discussion of cubic centimeter volumes of the implant. This is determined by the width of the patient’s breast and her choice of profile within the standard fill range for the saline implant. The 10% fill range from rated volume to maximum is the only other variable that can have some effect on perceived size of the breast as this usually amounts to 25–40 cc. This variable amount is an advantage with the use of saline implants and can be used to offset a minor volume difference between the two breasts or can be used to maximize or minimize the volume of the implant within a profile choice. This is agreed on with the patient at the preoperative visit and is not changed on the day of surgery or intraoperatively.

All patients should have preoperative pictures taken in standard views at the time of the preoperative appointment which should ideally be separate from the day of the procedure. The medical history and physical exam are also done at this time as well as the reinforcement of the postoperative instructions and restrictions.

Operative Technique

To a surgeon, the operative technique is the most important, but patient selection, preoperative evaluation and planning, considered choices, and postoperative care and healing are equally important to the overall successful outcome.

The most important thing in what is otherwise an elective cosmetic choice on the part of the patient is that the surgeon should choose the operative technique, not the patient. If the surgeon feels there is no difference in the choice from a purely outcome standpoint or the difference is related to value judgments by the patient, then the patient should get the choice. The surgeon should use the technique that is the best for this patient based on others’ experience, the literature on the procedure, and his or her own experience. In other words, the technique should be based on how to safely get the best result with the least likelihood of an unexpected outcome and the best match to the patient’s realistic goals and expectations.

For my patients, this means that the procedure will be done as an outpatient in my accredited office surgical suite or a hospital or other outpatient surgical facility. It will be done under intravenous sedation and local anesthesia or general anesthesia.² The breast implant will be placed through an inframammary crease incision in the subpectoral plane with adequate release of the pectoralis major muscle out of the lower pole of the breast.^3–5 The width (and therefore part of the determinate of the volume) of the implant will be determined by the width of the breast. The inframammary crease level will be adjusted if the distance from the nipple to the medial edge of the breast (under no tension) doesn’t match the distance from the nipple to the existing inframammary crease (under tension).

The advantages to the IMC incision are that it allows for a small and well-hidden scar, allows access to the subpectoral plane under direct vision without having to violate the breast tissue, and it is relatively easy to get back to the implant later on should that prove needed or desired.

The advantages to the subpectoral plane positioning are better short-term and long-term coverage of the implant, possible reduction in capsule contracture, possible less risk of bacterial contamination, and better separation of the breast parenchyma from the implant for viewing on mammography.

The patient gets to choose the surgeon, the facility, the method of anesthesia, whether the implant is saline-filled or gel-filled, and the profile of the implant (Table 22.2).

Table 22.2 The comparison of saline and gel for the patient

Today, the patient gets to choose whether she wants a saline-filled or gel-filled breast implant device.

With experience and proper attention to detail, saline-filled breast implants can be made to look just like a gel-filled implant.

Palpable feel of the saline-filled implant, ‘rippling’ that is felt and not seen in the upright position, cannot be avoided with a saline-filled device but can be graded and predicted at least for the immediate postoperative period.

Comparing the choice of saline-filled to gel-filled implants should not be described as which one is ‘better’, but should be discussed as what are the advantages and disadvantages of each and how important those factors are to the patient.

Gel-filled breast implants have one major advantage:

They feel more natural regardless of coverage.

And one major disadvantage:

There is no simple way to verify integrity.

Saline-filled breast implants have several minor advantages:

• Incision size can be less than half that for a gel implant • Cost is less than half that for a gel implant • Volume can be adjusted up to 10% above rated volume • Knowledge of the integrity of the device is not an issue.

And one major disadvantage: They don’t feel like tissue when they can be felt under tissue. The choice by the patient should involve knowing these issues, deciding how important they are to her, and how they relate to her degree of tissue coverage.

Pitfalls and How to Correct

Breast augmentation is a deceptively simple operation and a very common one. It’s often one where what many would consider poor results are thought to be acceptable and it’s possible to get away with a number of approaches that do not make much sense in the light of established plastic surgical principles. The idea, for example, that the patient can decide where to make the incision, what plane to put the implant in, what size the implant should be, and what the breast should look like is remarkably uncritical thinking on the part of experienced surgeons performing cosmetic procedures. They would not agree to such things for rhinoplasty but it seems to be acceptable for breast augmentation.

The goal of any surgical procedure to change the shape of an existing normal structure is to know what is feasible or reasonable, how to accomplish it, and then to get it healed that way. The idea is to have as much control over the outcome as is possible with available implants and techniques.

In many ways, breast augmentation is best thought of as an orthopedic procedure such as a hip replacement. The analogy is not perfect, but fitting a hip implant to a patient and what is feasible with current implants and techniques is very similar; the orthopedic surgeon does not ask the patient what size implant they’d like or what technique they want the surgeon to use. It’s based on measuring the patient and what’s worked well in the past and what the healing and long-term issues of the implant are.

The two most common general pitfalls in breast augmentation are inadequate preparation of the patient for the drawbacks and trade-offs of implants, particularly visible or palpable rippling and the problems of perception of size and shape with no way to measure and prove it.

Breast implants, particularly saline-filled ones, have to be sized, positioned, and filled properly to look natural. It is not possible to change the basic characteristics of a natural breast in primary cosmetic breast augmentation when the implant acts like pillow volume. Breasts cannot be moved closer together, lifted, turned, or filled in specific areas with volume that is soft enough to be a simulation of tissue volume without looking unnatural. One cannot choose a look for the breast any more than one can choose a style of nose.

The problem of what size a breast is before or after surgery and the patient’s ability to change their mind when they’re making a cosmetic choice to change the size of the breast to begin with is still with us. There is also no good way to clearly and fairly show the result expected or what the issue of implant palpability will feel like to the patient.

Long-term Problems and Issues

Postoperative Care

The principles of postoperative care for primary breast augmentation are similar to those of an orthopedic procedure. The operation is to get the implant in the correct position and the purpose of the postoperative period is to get it healed there. Then there is a period of rehabilitation to get the tissues recovered followed by resolution of sensation and incisional scar maturation. In the long term, if the implant maintains its integrity, it is an issue of how the breast and surrounding tissues behave over time.

Generally the capsule is thought to be formed and the implant healed in position by about ten days, but there is no simple way to verify this. I use 2 weeks as the healing period, with the first week being the most important. An elastic brassiere that is commercially available and very flexible and washable is used as a splint and kept on continuously for the first week. The patient must avoid pressure or movement to her breasts while they are trying to heal and not stir up bleeding or cause malposition. Sleeping position and arm use is restricted. Between restrictions and pain control issues, I recommend that the patient take the first week off and not be required to do anything, although not confined to bed or kept from showering with the brassiere on.

By the second week, the patient has been checked in the office, should not require narcotic pain medication, and can take the brassiere off briefly to shower and wash it. Sleeping position is still restricted but the arms can be used for normal activity up to shoulder height and lifting without major force is acceptable. This allows the patient to function normally for most activities except sports or heavy upper body exercise.

At the end of the second week, all restrictions are lifted and the patient is encouraged to return to full normal activity, wear whatever she wants or nothing, and use skin conditioning and massage to speed the rehabilitation of the breast. This usually takes another month. After-pictures can often be taken as early as 6 weeks. The sensation return and scar maturation is not expected at 6 weeks and full resolution of these can take a year.

All patients are followed without charge for a year and are encouraged to return for the year check up to retake after pictures, recheck the breast tissue, check the sensation and scar maturation, check the stability of the result, and discuss long-term issues again. Problems related to the result in the first year that are fixable are treated as revisions and done without surgical fee. (There is a facility fee to carry out the procedure.) The exception is the patient’s choice to change the size or type of the implant which is treated as a reaugmentation and charged, though at a reduced fee for patients where I did the original surgery.

Saline-filled implant deflations are easy to detect and replacement scheduling can often be initiated over the phone with a preoperative check to verify and discuss the options of simple replacement or replacement of both sides either of which are not overly complicated with a pre-existing IMC incision (Figs 22.5–22.7).

Conclusion

The patient can expect a natural looking result that looks like that of a gel implant but will not feel like one laterally and inferiorly to the extent that was predicted to the patient preoperatively. There should be no visible rippling in the upright position and only in extreme positions in those with very thin coverage. The size result is still subjective but should be in the range that was predicted by the patient’s preoperative size and her choice of profile of the implant.

The coverage of the implant cannot be stable or assured in the future whether it is a saline or gel-filled implant and, in fact, cannot be stable or assured even if the patient has no implant to cover. Using a small IMC incision with a saline implant allows for relatively easy access later on if the patient needs a replacement, chooses to change implant sizes, or to change to a gel-filled implant.